Eva C. Ihle, MD, PhD

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY 

In the early days of the shelter-in-place edict that was established in the San Francisco Bay Area in response to the COVID-19 pandemic, there was some debate about whether clinical services for patients with psychiatric illness were “

.” The department of psychiatry at my home institution installed a COVID-19 Task Force for patient care, appointed by departmental leadership and composed of clinicians, researchers, and administrative staff. A remarkable number of departmental meetings were held to eventually conclude that patients with psychiatric symptoms could still receive care from behavioral health clinicians, psychiatrists included, who were now expected to be working from home, even though it has been argued that psychiatry is an essential medical service and should be delivered in person if and when necessary.

 The strategy adopted for accomplishing this goal in the outpatient setting was conversion of all office-based appointments to telehealth visits on a secure internet platform.

The deliberation was more complicated and the decisions more controversial (and less universally adopted) in the hospital setting, for patients, both children and adults, who were psychiatrically hospitalized, or who were receiving care in general medical (non-psychiatric) hospitals and had psychiatric symptoms and/or comorbid psychiatric illness that required consultation-liaison psychiatric care. Directives from departmental leadership were rapidly evolving in the first few weeks of shelter-in-place, and included such decisions as not psychiatrically hospitalizing any patient aged 60 years or older or not having psychiatry residents interact directly with patients in emergency rooms. Fortunately, directives such as these were quickly revised, presumably through an iterative process between clinicians and leadership.

What took longer to establish were the policies for providing psychiatric 

 (C/L) service to medically hospitalized patients. These policies were hospital-specific and ultimately diverged on the basis of the philosophies held by the leaders of the respective C/L services. Each university-affiliated hospital was tasked with developing the protocols that would allow for consultations to be provided while taking into account the patient’s COVID-19 status. The solution that was adopted by the psychiatry C/L services of the 2 hospitals where I attend (a university-affiliated tertiary care center and a public safety net hospital) was a version of remote consultation via telehealth.

Most medical specialists who were still providing care and meeting the expectation of social distancing and infection control protocols in these hospitals embraced this technologic solution. Arguments in favor of this version of consultation were made to suggest that the quality of remote consultation would be adequate for the care provided. That may be true for straightforward cases. However, more often than not, there are cases that are far from straightforward, which flummox clinician efforts to use communication-enabling technology.

The university hospital where I am an attending on the adult 

 had years of experience with remote psychiatric consultation long before the COVID-19 pandemic. Our team provides consultation to multiple affiliated hospitals within the university health network but is headquartered in just one of them. From where we are stationed, our efforts to provide psychiatric consults via technology have been and remain fraught with challenges, both technologic and patient-based. This experience demonstrated the shortcomings of being far afield from patients.

We are dependent on: the hardware and software functioning adequately; the hospital staff designated as “resource nurses,” who serve as our bridge to the patient by wheeling in the computer cart on which the technology runs and being present with the patient while our team engages with them; and our clinical acumen to detect subtle changes in facial expression, affect, and engagement on a small screen. These technologic factors are moot when patients refuse to interact with their consultant over the computer or to even consent to such an intervention. Even when patients consent to a virtual visit, there may be circumstances when their level of disorganization, paranoia, distractibility, agitation, or distress prevents them from interacting in a meaningful way with their consultant.

The experiences of the adult psychiatry C/L service described above informed the child and adolescent psychiatrists (CAPs) providing consultation to our different pediatrics units, but in different ways. At one site, the patients in the children’s hospital were evaluated through remote consultation unless strict clinical criteria (altered mental status or 

 if not COVID-19 positive) were met to justify in-person (in-room) consultation (COVID-19 positive patients were not offered in-person psychiatric consultation). This algorithm required the primary pediatrics teams to engage with COVID-19 positive patients or their caregivers as a proxy for the CAPs (in the case of behavioral dysregulation or other symptoms that precluded the use of the telehealth device that the CAP C/L team relied on). Furthermore, the protocol did not accommodate patient preference. The COVID-19-negative patient confronting her cancer diagnosis had to engage with the team psychologist through a device and had to forego the opportunity for human contact.

The justification for remote consultation was the effort to minimize the number of staff exposed to COVID-19 and thus the likelihood of further contagion (presuming staff acted as vectors). However, the technology still needed human agents to manipulate it. Those humans were the same front-line staff who were expected to do the other tasks of patient care. Not only did this expectation suggest that their workload could be increased for the sake of supporting the CAP C/L team, but also that the safety of front-line staff could be forfeited for the safety of the consultants.

Another benefit that was touted was improved communication and/or 

 between psychiatry consultants and primary teams. For those of us doing proactive consults, and those who are fortunate enough to be integrated into inpatient teams, conversion to telehealth would have meant “retreating” from the frontlines and from our role as teammates. Instead, at the hospital where I am the CAP consultant to the inpatient Pediatrics unit, we developed a protocol (

) for conducting remote consultations for patients who were COVID-19 positive but not suicidal or homicidal to minimize interactions with the patient. We continued in-person consultations for everyone who was COVID-19 negative and “persons under investigation” (ie, patients whose test results were pending) or who were suicidal or homicidal (regardless of COVID-19 status). The difference between these circumstances would be the personal protective equipment (PPE) we would don (surgical masks and face-shields for COVID-19-negative patients; N95 respirators, face-shields, gowns, and gloves for COVID-19-positive patients). Of course, this protocol required the consumption of PPE.

Resources have been scarce, but hospitalized psychiatric patients are just as entitled to medical care as any other hospitalized patient, and those psychiatrists providing care need to be protected in the same way as other medical specialists. Physicians have always recognized that there are 

 inherent in treating patients with medical illness, and we have accepted this risk as a hallmark of our professional duties.

The protocol that we developed recognized the importance of being present for the inpatient teams and the challenges that telepsychiatry can pose for our patients who are acutely (psychiatrically) symptomatic. The first patient I evaluated using this protocol was an adolescent manifesting symptoms of excited catatonia; she paced throughout her room during the entirety of the interview and could barely attend to me while in the room with her. It is highly unlikely that I could have engaged her and redirected her over a video monitor.

It came as no surprise that in response to the 

 a number of remarkable policy changes occurred, perhaps more quickly than they otherwise would have. Several innovative programs arose at my home institution to meet the mental health needs of medical center staff: resilience and emotional well-being videos and webinars; self-care apps; family support programs; and direct assessment and treatment for faculty, staff, and trainees. What seemed to be missing from these efforts was comparable attention to the emotional and functional well-being of our patients with psychiatric illness.

It is becoming all the more clear that additional support for the increasing mental health needs of patients, especially those with pre-existing psychiatric illness, will be 

 So far, such support has been surprisingly limited. One program, our autism clinic, pivoted by establishing a virtual “coffee chat” support group function for the parents of patients with autism.

More data seem to be collected about the clinicians’ experiences of transitioning their services to telehealth platforms than the patients’ experiences of not being seen in person. Professional service organization listservs have become repositories for institutional strategies for converting (in-person) inpatient C/L services to 

. Ambitious members of these organizations have constructed methods papers about these strategies.

Attention is slowly beginning to shift from the process of providing telehealth to its consequences, especially in the area of 

 The consequences of these policy changes on the patients’ well-being are likely to be profound, and so far the impact of these changes on the needs of this vulnerable population has not been adequately explored. It makes no sense to deprive patients of the valuable service of in-person consultation if there are no clinical imperatives to do so. It can, of course, be a reasonable alternative to no care at all for patients who cannot access psychiatry through conventional means.

Technology is a fickle ally. It promises support but it falls short of authentic connection. In our effort to open new vistas for consulting on medically hospitalized patients with psychiatric symptoms, we should not lose sight of what our duty to them was meant to be.

Dedicating ourselves to the principles of social distancing may have resulted in the perceived abandonment of our patients. As our subspecialty comes to terms with the new normal of life in the post-COVID-19 era, it will be important to ensure that the emotional well-being of our patients is given at least as much attention as the mental health needs of our colleagues. Access to genuine care should not be relegated to virtual visits.

 is Health Sciences Clinical Professor in the Departments of Psychiatry & Behavioral Sciences and Pediatrics, Langley Porter Psychiatric Hospital and Clinics, UCSF Weill Institute for Neurosciences, University of California San Francisco, and Zuckerberg San Francisco General Hospital, San Francisco, CA. Dr Ihle has no disclosures regarding the subject of this article.

, for his support and mentorship, and to all of the physicians on the front lines providing medical care for patients during the COVID-19 pandemic.

1. Ihle EC. Psychiatry is an essential medical service during the COVID-19 pandemic. 

2. Wan W. The coronavirus pandemic is pushing America into a mental health crisis. 

May 4, 2020. Accessed September 15, 2020. 

https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus

3. Siwicki B. Survey: Americans’ perceptions of telehealth in the COVID-19 era. 

April 3, 2020. Accessed September 15, 2020. 

https://www.healthcareitnews.com/news/survey-americans-perceptions-telehealth-covid-19-era

Challenges faced by mental health providers and patients during the coronavirus 2019 pandemic due to technological barriers

Articles

In the early days of the pandemic, there was debate about whether clinical services for patients with psychiatric illness were “essential.” The evolution of psychiatric consultation-liaison services to medically hospitalized patients was no less complex.

What to Do When Being There Means Being Vulnerable

Autism is demanding increased attention by professional and lay audiences; prevalence seems to be increasing. There are differing opinions about whether the increase is due to greater recognition and reporting, diagnostic expansion and substitution, or increasing acceptability. On the other hand, the increase may be a consequence of environmental toxins or infectious and immune vulnerability and epigenetics or perhaps a combination of social and environmental factors.

Clearly, autism has a large genetic component and multiple genes are involved in various combinations. Nevertheless, the prevalence of autism in the United States and in other countries has increased exponentially; this trend would not happen with a purely genetic disorder. Most autism researchers accept a theory of etiology that starts with a genetic neurodevelopmental vulnerability combined with an environmental stressor through such epigenetic processes as immune function.

Increasingly, researchers and clinicians refer to autism to describe a wide variety of phenotypes that start with genes and gene expression and range through a variety of metabolic functions to symptoms that cluster diagnostically but have a great deal of individuality. Symptoms can range from mild to severe and may be associated with mental retardation; GI and neurological involvement; and behavioral, emotional, cognitive, and whole body pathology.

Here we discuss diagnostic assessment and classification, co-occurring or comorbid psychiatric disorders and their differential diagnosis, the medical workup, and possible medical comorbidities. We also review a model for psychosocial treatment as well as psychopharmacological and alternative treatments. We conclude with a brief look at the future of research and treatment.

The term “autism (or autistic) spectrum disorder” (ASD) is likely to be replaced with “pervasive developmental disorder” in DSM-5. ASD is a collection of neurodevelopmentally based conditions of social and communicative impairments, each with varying severity and broadness of expression.

Autism was originally described by Leo Kanner in the early 1940s and termed “early infantile autism” of unknown etiology. By the 1960s, work on high concordance of autism in monozygotic twins and lower concordance in dizygotic twins and siblings led to the present-day understanding of ASD as a developmental and neurobiological condition with heterogeneous genetic and possible epigenetic triggers.

Diagnosis of ASD remains an empirical and behavioral procedure with no clear or single biological marker or assay. This has made reliable and valid diagnosis problematic: signs of ASD selected for inclusion in DSM have had fairly high diagnostic sensitivity but often poor specificity.

 Symptoms of ASD overlap with those of other neurodevelopmental disorders. Accurate differential diagnosis and diagnosis of comorbid conditions in ASD are therefore difficult.

The best practice for clinical assessment of ASD involves multiple methods of measuring multiple traits (

). Both parents and child contribute to data collection via interview and record review. The child is also observed directly or on video in the home, at school, and in the clinic under structured and unstructured conditions.

 The Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedule (ADOS) are considered to be the gold standard in ASD diagnosis and are widely used in research.

Because a behavior can reflect different etiologies and symptoms can overlap, other disorders need to be carefully considered. Within the differential for ASD are anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and even prodromal schizophrenia or schizoid personality disorder.

When children are anxious, particularly when they have symptoms consistent with obsessive-compulsive disorder, they can manifest an inflexibility about routines (serving to bind their anxiety) and exhibit tics or behavioral compulsions that can be mistaken for stereotypies. Likewise, it can be difficult to delineate anxiety from the overwhelming biological basis for ASD in which learning deficits lead to anxious behavior.

Children with ADHD can seem socially impaired. But rather than having a deficit in theory of mind, the ability to understand another’s perspective through one’s own similar reasoning and experience, these children miss social cues (because they do not attend to them) or behave impulsively around peers, which can result in their being ostracised. The social withdrawal associated with thought disorders can be mistaken for the impairments in social interaction characteristic of ASD.

CHECKPOINTS 
? Signs of autism spectrum disorder (ASD) selected for inclusion in DSM have had fairly high sensitivity to the clinical diagnosis of autism, but they often show poor specificity.

? A diagnosis of autism can be made only if the child’s social interactions are not commensurate with his or her developmental level. 

? Psychiatric comorbidities, such as anxiety and attention-deficit/hyperactivity disorder, and medical comorbidities, such as epilepsy, sleep disorders, and Tourette syndrome, are frequent in ASD.

? ASD is heterogeneous in expression, and treatment plans must target ASD and comorbid disorders that may require integrated yet separate treatment.. 

? Psychopharmacological agents can help with symptoms of ASD, such as irritability, impulsivity, and anxiety; however, they do not seem to help directly with core symptoms of social reciprocity or communication, although they may do so indirectly through improved availability for treatment.

ASD can also be misdiagnosed in children who have a language disorder.

 Communication deficits can lead to social impairment, but these are secondary to limitations in reciprocal exchanges (and resultant frustration). In addition, the classification of receptive and expressive language disorders in DSM is nosologically different from American Speech-Language-Hearing Association standards.

While misdiagnosis can be a dilemma, overlooking a diagnosis can also be challenging. It is unclear why the diagnosis of intellectual disability is often missed, given that 50% to 70% of children with ASD have some level of intellectual disability.

Clinicians may be reluctant to make this diagnosis in children who are difficult to assess, or to discuss this diagnosis with parents. Alternatively, assessment of cognitive functioning may not be part of the clinical evaluation. Ideally, patients should undergo a battery of clinical assessments that includes a test of cognitive functioning. A diagnosis of autism can be made only if the child’s social interactions are not commensurate with his or her developmental level.

It is worth noting that disorders that can be mistaken for ASD can co-occur with ASD. The diagnosis of ASD does not exclude the possibility of a comorbid brain disorder. ADHD and anxiety disorders are frequently associated with ASD, with mood disorders occurring less frequently.

ASD is a heterogeneous set of disorders that is occasionally associated with (and secondary to) a particular neurological disease. In this situation, syndromic autism, there can be autistic features (ie, behaviors that appear to have their basis in a deficit in theory of mind) associated with, for example, tuberous sclerosis, fragile X syndrome, and agenesis of the corpus callosum.

Medical comorbidities, such as epilepsy, sleep disorders, and Tourette syndrome, are frequent in ASD. Their recognition and treatment form a core component of symptom management in affected individuals and highlight the importance of a multidisciplinary health care team.

Epilepsy occurs in up to one-third of individuals with ASD and suggests an imbalance of neural excitation and inhibition. Seizure onset has been noted to present during 2 peak periods: early childhood and adolescence.

 In addition, there is some suggestion of an increased risk of epilepsy in females and individuals with intellectual disability.

 Although there are no primary seizure types specifically associated with idiopathic ASD, specific neurogenetic disorders (eg, tuberous sclerosis complex, fragile X syndrome, chromosome 15q duplication syndrome, 

-related conditions) confer increased risk of ASD and epilepsy.

 There are also reports of higher rates of epileptiform electroencephalograms in children who do not have clinical seizures.

Sleep disorders affect up to two-thirds of children with ASD.

 Insomnias are predominant; however, parasomnias, breathing disorders, and movement disorders have also been reported.

Recent work in ASD genetics suggests a relationship between polymorphisms in the biological clock genes, 

 Although the effects of sleep disorders are difficult to separate from the effects of neurodevelopmental disability in general, insomnia is important to treat because it may exacerbate challenging behaviors, hyperactivity, cognitive deficits, headaches, and seizure frequency.

 For sleep difficulties related to disrupted circadian cycles, it may be helpful to limit daytime sleeping and caffeine intake and to ensure regular exercise. Exogenous treatment with melatonin may decrease time to sleep onset.

In patients with ASD, the prevalence of Tourette syndrome is increased (6.5%).

 Unifying theories posit a common genetic liability factor for ASD and tics; however, these theories have not been substantiated. Complex motor tics can be distinguished from common ASD stereotypies in that complex motor tics are involuntary, are quick and random, and tend to subside when an individual is engrossed in an activity. Behavioral and pharmacological interventions are only indicated when tics limit function and comfort.

Psychoeducational and behavioral treatments

Evidence-based ASD treatment must be intensive and individualized, with learning opportunities that are an integral part of educational and social interactions.

 Treatments for ASD begin with an understanding that the syndrome is heterogeneous in expression and that treatment plans must target ASD rather than comorbid disorders that may require integrated yet separate treatment. From the psychoeducational or behavioral treatment perspective, one heuristic for conceptualizing this clinical variability is to functionally translate DSM symptoms into autism-specific learning disabilities and autism-specific learning styles. This allows the clinician to think in terms of an autism treatment “toolbox” that can be used to assess a patient’s learning disabilities and learning styles and to choose specific intervention strategies to target them (

 Research standards support ASD treatments that are behavioral in meth-odology and developmental with respect to curriculum content.

Psychopharmacological agents can help with symptoms associated with ASD, such as irritability, impulsivity, anxiety, cognitive disorganization, aggression, difficulty in shifting attention from one area of interest to another, and distractible inattention. However, these medications do not seem to help directly with core symptoms of social reciprocity or communication, although improvement in the above-mentioned symptoms can help indirectly.

In 2006, the FDA approved risperidone to treat irritability in autism.

 On the basis of 2 studies, aripiprazole was approved for the same indication in November 2009.

 Other atypical antipsychotics have also been found to be effective in open-label trials. Except for ziprasidone, all are associated with weight gain, at least initially.

SSRIs have long been used to treat impulsivity, difficulty in shifting attention, anxiety, and repetitive behaviors on the basis of the finding of low serotonin levels in patients with ASD. However, a large, multisite, placebo-controlled trial of citalopram in ASD did not find significant differences on the Clinical Global Impression Improvement (CGI-I) scale or the Children’s Yale-Brown OC [obsessive-compulsive] Scale (CY-BOCS).

 Factors that may account for this could have been the 30% placebo response rate.

Other medications that might be judiciously considered in the treatment of ASD include stimulants, a2-adrenergic agonists, divalproex, and memantine.

 Alternative treatments under investigation include melatonin, ω-3 fatty acids, methyl B12, the casein-/gluten-free diet, digestive enzymes, hyperbaric oxygen therapy, and chelation. Most alternative treatments do not have published studies to guide treatment selection and for some, there is a question of safety.

The study of autism is progressing rapidly. Early identification and intervention is increasingly possible and effective.

 Further delineation of the gene-environment interaction theories of etiology are coming from large, collaborative studies. The number of treatment studies lags far behind that of studies of genetics and other etiologies, but the number is growing because of more sophisticated ideas about etiology and treatment targets.

Community organizations, school personnel, and treatment providers are gaining increasing skill at personalizing treatments for patients with autism, with significant improvements in outcome. The rising number of adults with ASD presents a considerable challenge for suitable housing, employment, and effective interventions. It is likely that facing these challenges and the new understandings that are being developed will benefit not only people with ASD but all people with neurodevelopmental disorders.

 Pardo CA, Eberhart CG. The neurobiology of autism. 

 Herbert MR. Contributions of the environment and environmentally vulnerable physiology to autism spectrum disorders. 

 Andrews G, Pine DS, Hobbs MJ, et al. Neurodevelopmental disorders: cluster 2 of the proposed meta-structure for DSM-V and ICD-11. 

Helping Children With Autism Learn: A Guide to Treatment Approaches for Parents and Professionals. 

New York: Oxford University Press; 2003.


 Siegel B, Ficcaglia M, Hayer C, et al. Treatment of pervasive developmental disorders. In: Weller E, McDermott J, Gabbard GO, eds.

 Gabbard’s Treatment of Psychiatric Disorders. 

4th ed. Washington, DC: American Psychiatric Association Press; 2007:79-92.


. Washington, DC: National Academy Press; 2001.


Autism is demanding increased attention by professional and lay audiences; prevalence seems to be increasing. There are differing opinions about whether the increase is due to greater recognition and reporting, diagnostic expansion and substitution, or increasing acceptability.

Eva C. Ihle, MD, PhD

Articles

What to Do When Being There Means Being Vulnerable

Update on Autism